INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Livengrin Counseling Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agnecy, or organization to whom the disclosure was to be made to on an informed and voluntary consent forms in one of twelve client records.Client #3 was admitted into the Partial Hospitalization level of care on November 10, 2020 and was discharged November 24, 2020. A release information form was signed and dated by the client on November 10, 2020; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure was to be made to. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Manager will review with staff the proper way to complete consents. Audits will be performed through random chart selection by the Program Manager to ensure continued compliance. Team members with continued instances of none compliance may be subject to corrective action. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services the client was to receive on the client's individual treatment plan in two of six applicable client records reviewed. Client #4 was admitted on July 7, 2020 and was discharged August 5. 2020. The comprehensive treatment plan was dated July 7, 2020 and was missing the frequency of traeatment services the client was to receive.Client #6 was admitted on August 17, 2020 and was discharged September 8, 2020. The comprehensive treatment plan was dated September 8, 2020 and was missing the frequency of traeatment services the client was to receive. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Program Manager will review with staff the proper treatment plan documentation requirements. Audits will be performed through random chart selection by the Program Manager to ensure continued compliance. Team members with continued instances of none compliance may be subject to corrective action. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide individual counseling sessions to a client at least twice weekly in three of six applicable client records reviewed.Client # 2 was admitted on February 24, 2021 and was active at the time of inspection. There was only documentation of either zero or one individual session per week for the duration of the client's treatment episode.Client #4 was admitted on July 7, 2020 and was discharged August 5. 2020. There was only documentation of either zero or one individual session per week for the duration of the client's treatment episode.Client #6 was admitted on August 17, 2020 and was discharged September 8, 2020. There was only documentation of either zero or one individual session per week for the duration of the client's treatment episode.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager will review with staff the proper treatment plan documentation requirements. Audits will be performed through random chart selection by the Program Manager to ensure continued compliance. Team members with continued instances of none compliance may be subject to corrective action. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in one of three applicable records reviewed.Client # 12 was admitted into the outpatient level of care on May 28, 2019 and was discharged July 24, 2020. There was no follow-up information documented in the record as of the date of the inspection.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Program Manager will review with staff the proper documentation requirements regarding documented follow up. Audits will be performed through random chart selection by the Program Manager to ensure continued compliance. Team members with continued instances of none compliance may be subject to corrective action. The organizaiton is also working to complete follow up through our EHR's patient portal. |